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Abuelazm M, Khildj Y, Ibrahim AA, Mahmoud A, Amin AM, Gowaily I, Khan U, Abdelazeem B, Brašić JR. Intensive Blood Pressure Control After Endovascular Thrombectomy for Acute Ischemic Stroke: a Systematic Review and Meta-Analysis. Clin Neuroradiol 2024:10.1007/s00062-024-01391-6. [PMID: 38453701 DOI: 10.1007/s00062-024-01391-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 01/22/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND AND PURPOSE Optimal clinical outcome with successful recanalization from endovascular thrombectomy (EVT) requires optimal blood pressure (BP) management. We aimed to evaluate the efficacy and safety of the intensive BP target (< 140 mm Hg) versus the standard BP target (< 180 mm Hg) after EVT for acute ischemic stroke. METHODS We conducted a systematic review and meta-analysis synthesizing evidence from randomized controlled trials (RCTs) obtained from PubMed, Embase Cochrane, Scopus, and WOS until September 7th, 2023. We used the fixed-effect model to report dichotomous outcomes using risk ratio (RR) and continuous outcomes using mean difference (MD), with a 95% confidence interval (CI). PROSPERO ID CRD42023463206. RESULTS We included four RCTs with 1559 patients. There was no difference between intensive BP and standard BP targets regarding the National Institutes of Health Stroke Scale (NIHSS) change after 24 h [MD: 0.44 with 95% CI (0.0, 0.87), P = 0.05]. However, the intensive BP target was significantly associated with a decreased risk of excellent neurological recovery (mRS ≤ 1) [RR: 0.87 with 95% CI (0.76, 0.99), P = 0.03], functional independence (mRS ≤ 2) [RR: 0.81 with 95% CI (0.73, 0.90), P = 0.0001] and independent ambulation (mRS ≤ 3) [RR: 0.85 with 95% CI (0.79, 0.92), P < 0.0001]. CONCLUSIONS An intensive BP target after EVT is associated with worse neurological recovery and significantly decreased rates of functional independence and independent ambulation compared to the standard BP target. Therefore, the intensive BP target should be avoided after EVT for acute ischemic stroke.
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Affiliation(s)
| | - Yehya Khildj
- Faculty of Medicine, University of Algiers, Algiers, Algeria
| | | | | | | | | | - Ubaid Khan
- Faculty of Medicine, King Edward Medical University, Lahore, Pakistan
| | - Basel Abdelazeem
- Department of Cardiology, West Virginia University, West Virginia, USA
| | - James Robert Brašić
- Section of High-Resolution Brain Positron Emission Tomography Imaging, Division of Nuclear Medicine and Molecular Imaging, The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Behavioral Health, New York City Health and Hospitals/Bellevue, New York, NY, USA
- Department of Psychiatry, New York University Grossman School of Medicine, New York University Langone Health, New York, NY, USA
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De Georgia M, Bowen T, Duncan KR, Chebl AB. Blood pressure management in ischemic stroke patients undergoing mechanical thrombectomy. Neurol Res Pract 2023; 5:12. [PMID: 36991520 PMCID: PMC10061853 DOI: 10.1186/s42466-023-00238-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 03/14/2023] [Indexed: 03/31/2023] Open
Abstract
The relationship between presenting blood pressure in acute ischemic stroke patients and outcome is complex. Several studies have demonstrated a U-shaped curve with worse outcomes when blood pressure is high or low. The American Heart Association/American Stroke Association guidelines recommend values of blood pressure < 185/110 mmHg in patients treated with intravenous t-PA and "permissive hypertension" up to 220/120 mmHg in those not treated with intravenous t-PA. The optimal blood pressure target is less clear in patients undergoing mechanical thrombectomy. Before thrombectomy, the guidelines recommend a blood pressure < 185/110 mmHg though patients with even lower systolic blood pressures may have better outcomes. During and after thrombectomy, the guidelines recommend a blood pressure < 180/105 mmHg. However, several studies have suggested that during thrombectomy the primary goal should be to prevent significant low blood pressure (e.g., target systolic blood pressure > 140 mmHg or MAP > 70 mmHg). After thrombectomy, the primary goal should be to prevent high blood pressure (e.g., target systolic blood pressure < 160 mmHg or MAP < 90 mmHg). To make more specific recommendations, large, randomized-control studies are needed that address factors such as the baseline blood pressure, timing and degree of revascularization, status of collaterals, and estimated risk of reperfusion injury.
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Affiliation(s)
- Michael De Georgia
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | - Theodore Bowen
- Department of Neurology, MetroHealth Medical Center, Cleveland, OH, USA
| | - K Rose Duncan
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Alex Bou Chebl
- Department of Neurology, Henry Ford Medical Center, Detroit, MI, USA
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Maïer B, Gory B, Chabanne R, Tavernier B, Balanca B, Audibert G, Thion LA, Le Guen M, Geeraerts T, Calviere L, Degos V, Lapergue B, Richard S, Djarallah A, Mophawe O, Boursin P, Le Cossec C, Blanc R, Piotin M, Mazighi M, Gayat E. Effect of an individualized versus standard blood pressure management during mechanical thrombectomy for anterior ischemic stroke: the DETERMINE randomized controlled trial. Trials 2022; 23:598. [PMID: 35883180 PMCID: PMC9317065 DOI: 10.1186/s13063-022-06538-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 07/11/2022] [Indexed: 11/10/2022] Open
Abstract
Background Hypotension and blood pressure (BP) variability during endovascular therapy (EVT) for acute ischemic stroke (AIS) due to an anterior large vessel occlusion (LVO) is associated with worse outcomes. However, the optimal BP threshold during EVT is still unknown given the lack of randomized controlled evidence. We designed the DETERMINE trial to assess whether an individualized BP management during EVT could achieve better functional outcomes compared to a standard BP management. Methods The DETERMINE trial is a multicenter, prospective, randomized, controlled, open-label, blinded endpoint clinical trial (PROBE design). AIS patients with a proximal anterior LVO are randomly assigned, in a 1:1 ratio, to an experimental arm in which mean arterial pressure (MAP) is maintained within 10% of the first MAP measured before EVT, or a control arm in which systolic BP (SBP) is maintained within 140–180 mm Hg until reperfusion is achieved or artery closure in case of EVT failure. The primary outcome is the rate of favorable functional outcomes, defined by a modified Rankin Scale (mRS) between 0 and 2 at 90 days. Secondary outcomes include excellent outcome and ordinal analysis of the mRS at 90 days, early neurological improvement at 24 h (National Institutes of Health Stroke Scale), final infarct volume, symptomatic intracranial hemorrhage rates, and all-cause mortality at 90 days. Overall, 432 patients will be included. Discussion DETERMINE will assess the clinical relevance of an individualized BP management before reperfusion compared to the one size fits all approach currently recommended by international guidelines. Trial registration ClinicalTrials.gov, NCT04352296. Registered on 20th April 2020. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06538-9.
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Affiliation(s)
- Benjamin Maïer
- Interventional Neuroradiology Department, Hôpital Fondation Adolphe de Rothschild, 29 rue Manin, 75019, Paris, France. .,Université Paris-Cité, Paris, France.
| | - Benjamin Gory
- Diagnostic and Therapeutic Neuroradiology Department, CHRU-Nancy, Université de Lorraine, INSERM U124, Nancy, France
| | - Russell Chabanne
- Department of Anesthesia, Critical Care and Peri-Operative Medicine, Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France
| | - Benoît Tavernier
- Department of Anesthesia and Critical Care, University Hospital, Lille, F-59000, Lille, France.,Université Lille, ULR 2694 - METRICS, F-59000, Lille, France
| | - Baptiste Balanca
- Department of Neurological Anesthesiology and Intensive Care, Hospices Civils de Lyon, Hôpital Pierre Wertheimer, Groupement Hospitalier Est, 59 Boulevard Pinel, 69500, Bron, Lyon, France.,Lyon's Neuroscience Research Center, INSERM U1028/CNRS UMR 5292, Lyon 1 University, Lyon, France
| | | | - Laurie-Anne Thion
- Anesthesiology Department, Hôpital fondation A. de Rothschild, Paris, France
| | - Morgan Le Guen
- Anesthesiology Department, Foch Hospital, Suresnes, France
| | - Thomas Geeraerts
- Anesthesiology and Critical Care department, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Lionel Calviere
- Neurology Department, University Hospital of Toulouse, Toulouse, France
| | - Vincent Degos
- Department of Anesthesia, Critical Care and Peri-Operative Medicine, APHP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France.,INSERM UMR 1141, Paris, France
| | | | - Sebastien Richard
- Neurology Department, CHRU-Nancy, Université de Lorraine, Nancy, France
| | - Azeddine Djarallah
- Clinical Research Unit, Hôpital fondation A. de Rothschild, Paris, France
| | - Ornellia Mophawe
- Clinical Research Unit, Hôpital fondation A. de Rothschild, Paris, France
| | - Perrine Boursin
- Interventional Neuroradiology Department, Hôpital Fondation Adolphe de Rothschild, 29 rue Manin, 75019, Paris, France
| | - Chloé Le Cossec
- Clinical Research Unit, Hôpital fondation A. de Rothschild, Paris, France
| | - Raphael Blanc
- Interventional Neuroradiology Department, Hôpital Fondation Adolphe de Rothschild, 29 rue Manin, 75019, Paris, France
| | - Michel Piotin
- Interventional Neuroradiology Department, Hôpital Fondation Adolphe de Rothschild, 29 rue Manin, 75019, Paris, France
| | - Mikael Mazighi
- Interventional Neuroradiology Department, Hôpital Fondation Adolphe de Rothschild, 29 rue Manin, 75019, Paris, France.,Université Paris-Cité, Paris, France
| | - Etienne Gayat
- Université Paris-Cité, Paris, France.,Anesthesiology Department, Hôpital Lariboisière, Paris, France
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Abstract
PURPOSE OF REVIEW Blood pressure management in acute stroke has long been a matter of debate. Epidemiological data show that high blood pressure is associated with death, disability and early stroke recurrence, whereas the pathophysiological rationale for ensuring elevated blood pressure in order maintain adequate cerebral perfusion remains a pertinent argument, especially in ischaemic stroke. RECENT FINDINGS The European Stroke Organisation Guidelines on blood pressure management in acute ischaemic stroke and intracerebral haemorrhage provide recommendations for the appropriate management of blood pressure in various clinical acute stroke settings. SUMMARY In this narrative review, we provide specific updates on blood pressure management in ICH, blood pressure management in the setting of reperfusion therapies for ischaemic stroke, and the evidence for the use of induced hypertension in patients with acute ischaemic stroke in the light of the recent guidelines.
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Affiliation(s)
- Rajiv Advani
- Stroke Unit, Department of Neurology, Oslo University Hospital
- The Neuroscience Research Group, Stavanger University Hospital, Stavanger, Norway
| | - Else Charlotte Sandset
- Stroke Unit, Department of Neurology, Oslo University Hospital
- The Norwegian Air Ambulance Foundation, Oslo
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